Provider Demographics
NPI:1164794400
Name:STEPHENS, AMANDA ALAINE
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:ALAINE
Last Name:STEPHENS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1717 NORFOLK AVE
Mailing Address - Street 2:ATTN: REHABCARE
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79416-6099
Mailing Address - Country:US
Mailing Address - Phone:806-281-6232
Mailing Address - Fax:806-281-6233
Practice Address - Street 1:1717 NORFOLK AVE
Practice Address - Street 2:ATTN: REHABCARE
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79416-6099
Practice Address - Country:US
Practice Address - Phone:806-281-6232
Practice Address - Fax:806-281-6233
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-02
Last Update Date:2014-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX105878235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX149984001Medicaid
TX207164901Medicaid
TX676535Medicare PIN
TX207164901Medicaid